Management of High and Very High-Risk Subjects with Familial Hypercholesterolemia: Results from an Observational Study in Bulgaria.

BACKGROUND: Familial hypercholesterolaemia (FH) is a genetic disorder causing accelerated atherosclerosis and premature cardiovascular disease (CVD). This retrospective observational study examined the clinical characteristics and management of FH subjects in Bulgaria over a 12-month period. MATERIALS AND METHODS: Twelve cardiology sites participated in this study from May 2015 to May 2016. Eligible subjects had at least two routine low-density lipo-protein cholesterol (LDL C) measurements and a prescription for lipid-lowering therapy (LLT) at the start of the observation period. Mean values for gender, age and cardiovascular (CV) event history at baseline and LDL-C over time were estimated. RESULTS: Of the 220 eligible subjects, 196 fulfilled the criteria for FH diagnosis: 27 definite, 94 probable and 75 possible. Mean age at enrolment was 54.4 years and 64.1% of subjects were male. Mean CV risk classification at baseline was 26.8% high-risk (HR) and 73.2% very high-risk (VHR). Mean LDL-C was 5.6 mmol/L at enrolment and 4.1 mmol/L at last observation visit (12 months). The ESC/EAS Guideline LDL-C targets (applicable at the time of the study) were achieved by 14.5% of HR and 5.0% of VHR subjects. Most subjects (n=219) received statins. One subject was statin intolerant (ezetimibe therapy). Intensive statin treatment (atorvastatin 40-80 mg/daily and rosuvastatin 20-40 mg/daily) was used in 38.6% of individuals during the observation period and 10% of subjects received combination therapy (statin plus ezetimibe or other LLT). CONCLUSIONS: Most subjects with FH do not reach the ESC/EAS defined LDL-C targets. Early identification and physician education may improve FH management.

Association between community noise and adiposity in patients with cardiovascular disease.

INTRODUCTION: This study aimed to explore the effect of community noise on body mass index (BMI) and waist circumference (WC) in patients with cardiovascular disease (CVD). MATERIALS AND METHODS: A representative sample of 132 patients from three tertiary hospitals in the city of Plovdiv, Bulgaria was collected. Anthropometric measurements were linked to global noise annoyance (GNA) based on different residential noise annoyances, day-evening-night (Lden), and nighttime (Lnight) road traffic noise exposure. Noise map Lden and Lnight were determined at the living room and bedroom façades, respectively, and further corrected to indoor exposure based on the window-opening frequency and soundproofing insulation. RESULTS AND DISCUSSION: Results showed that BMI and WC increased (non-significantly) per 5 dB. The effect of indoor noise was stronger in comparison with that of outdoor noise. For indoor Lden, the effect was more pronounced in men, those with diabetes, family history of diabetes, high noise sensitivity, using solid fuel/gas for domestic heating/cooking, and living on the first floor. As regards indoor Lnight, its effect was more pronounced in those with low socioeconomic status, hearing loss, and using solid fuel/gas for domestic heating/cooking. GNA was associated with lower BMI and WC. CONCLUSION: Road traffic noise was associated with an increase in adiposity in some potentially vulnerable patients with CVD.

An Incidental Finding of Heart Echinococcosis in a Patient with Infective Endocarditis: a Case Report.

Echinococcosis is a cosmopolitan zoonotic parasitic disease caused by infection with the larval stage of tapeworms from the Echinococcus genus, most commonly Echinococcus granulosus. According to WHO, more than 1 million people are affected by hydatid disease at any time.1 About 10% of the annual cases are not officially diagnosed.2 In humans, the disease is characterized by development of three-layered cysts. The cysts develop primarily in the liver and the lungs, but can also affect any other organ due to the spreading of the oncospheres. Cardiac involvement is very uncommon - only about 0.01-2% of all cases.4,5 In most cases, the cysts develop asymptomatically, but heart cysts could manifest with chest pain, dyspnea, cough, hemophtisis and can complicate with rupture. Diagnosis is based on a number of imaging techniques and positive serological tests. Treatment for cardiac localization is almost exclusively surgical. We present a case of an incidental finding of an echinococcal cyst in the left atrium (rarest possible localization of heart echinococcosis) in a patient, admitted for infective endocarditis.

Community Noise Exposure and its Effect on Blood Pressure and Renal Function in Patients with Hypertension and Cardiovascular Disease.

BACKGROUND: Road traffic noise (RTN) is a risk factor for cardiovascular disease (CVD) and hypertension; however, few studies have looked into its association with blood pressure (BP) and renal function in patients with prior CVD. AIM: This study aimed to explore the effect of residential RTN exposure on BP and renal function in patients with CVD from Plovdiv Province. MATERIALS AND METHODS: We included 217 patients with ischemic heart disease and/or hypertension from three tertiary hospitals in the city of Plovdiv (March - May 2016). Patients' medical history, medical documentation, and medication regimen were reviewed, and blood pressure and anthropometric measurements were taken. Blood samples were analyzed for creatinine, total cholesterol, and blood glucose. Participants also filled a questionnaire. Glomerular filtration rate was estimated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. All participants were asked about their annoyance by different noise sources at home, and those living in the city of Plovdiv (n = 132) were assigned noise map Lden and Lnight exposure. The effects of noise exposure on systolic blood pressure (SBP), diastolic blood pressure (DBP), and estimated glomerular filtration rate (eGFR) were explored using mixed linear models. RESULTS: Traffic noise annoyance was associated with higher SBP in the total sample. The other noise indicators were associated with non-significant elevation in SBP and reduction in eGFR. The effect of Lden was more pronounced in patients with prior ischemic heart disease/stroke, diabetes, obesity, not taking Ca-channel blockers, and using solid fuel/gas at home. Lnight had stronger effect among those not taking statins, sleeping in a bedroom with noisy façade, having a living room with quiet façade, and spending more time at home. The increase in Lden was associated with a significant decrease in eGFR among men, patients with ischemic heart disease/stroke, and those exposed to lower air pollution. Regarding Lnight, there was significant effect modification by gender, diabetes, obesity, and time spent at home. In some subgroups, the effect of RTN was statistically significant. CONCLUSIONS: Given that generic risk factors for poor progression of cardiovascular diseases cannot be controlled sufficiently at individual level, environmental interventions to reduce residential noise exposure might result in some improvement in the management of blood pressure and kidney function in patients with CVD.

Sex Differences in Clinical Characteristics and Outcomes After Myocardial Infarction With Low Ejection Fraction: Insights From PARADISE-MI.

Background Studies demonstrated sex differences in outcomes following acute myocardial infarction, with women more likely to develop heart failure (HF). Sacubitril/valsartan has been shown to reduce cardiovascular death and HF hospitalizations in patients with HF with reduced ejection fraction. Methods and Results A total of 5661 patients (1363 women [24%]) with acute myocardial infarction complicated by reduced left ventricular ejection fraction (≤40%), pulmonary congestion, or both and ≥1 of 8 risk-augmenting factors were randomized to receive sacubitril/valsartan or ramipril. The primary outcome was cardiovascular death or incident HF. Baseline characteristics, clinical outcomes, and safety events were compared according to sex, a prespecified subgroup. Female participants were older and had more comorbidities. After multivariable adjustment, women and men were at similar risks for cardiovascular death or all-cause death. Women were more likely to have first HF hospitalization (hazard ratio [HR], 1.34 [95% CI, 1.05-1.70]; P=0.02) and total HF hospitalizations (HR, 1.39 [95% CI, 1.05-1.84]; P=0.02). Sex did not significantly modify the treatment effect of sacubitril/valsartan compared with ramipril on the primary outcome (P for interaction=0.11). Conclusions In contemporary patients who presented with reduced left ventricular ejection fraction, pulmonary congestion, or both, following acute myocardial infarction, women had a higher incidence of HF during follow-up. Sex did not modify the treatment effect of sacubitril/valsartan relative to ramipril. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02924727.

European Society of Cardiology quality indicators for the care and outcomes of adults with heart failure. Developed by the Working Group for Heart Failure Quality Indicators in collaboration with the Heart Failure Association of the European Society of Cardiology.

AIMS: To develop a suite of quality indicators (QIs) for the evaluation of the quality of care for adults with heart failure (HF). METHODS AND RESULTS: We followed the ESC methodology for QI development, which involved (i) the identification of the key domains of care for the management of HF by constructing a conceptual framework of HF care, (ii) the development of candidate QIs by conducting a systematic review of the literature, (iii) the selection of the final set of QIs using a modified Delphi method, and (iv) the evaluation of the feasibility of the developed QIs. The Working Group comprised experts in HF management including Task Force members of the 2021 European Society of Cardiology (ESC) Clinical Practice Guidelines for HF, members of the Heart Failure Association (HFA), Quality Indicator Committee and a patient representative. In total, 12 main and 4 secondary QIs were selected across five domains of care for the management of HF: (1) structural framework, (2) patient assessment, (3) initial treatment, (4) therapy optimization, and (5) assessment of patient health-related quality of life. CONCLUSION: We present the ESC HFA QIs for HF, describe their development process and provide the scientific rationale for their selection. The indicators may be used to quantify and improve adherence to guideline-recommended clinical practice and thus improve patient outcomes.

Is everything clear about Tako-tsubo syndrome?

INTRODUCTION: Tako-tsubo syndrome is a novel cardio-vascular disease affecting predominantly postmenopausal women exposed to unexpected strong emotional or physical stress, in the absence of significant coronary heart disease. It is characterized by acute onset of severe chest pain and/or acute left ventricular failure, ECG-changes, typical left ventricular angiographic findings, good prognosis and positive resolution of the morphological and clinical manifestations. First described in 1990 in Japan by Sato, Tako-tsubo cardiomyopathy is characterized by transient contractile abnormalities of the left ventricle, causing typical left ventricular apical ballooning at end-systole with concomitant compensatory basal hyperkinesia. There are also atypical forms, presenting with left ventricular systolic dysfunction which affects the mid-portions of the left ventricle. The etiology of the disease still remains unclear. Many theories have been put forward about the potential underlying pathophysiological mechanisms that may trigger this syndrome among which are the theory of catecholamine excess, the theory of multivessel coronary vasospasm, the ischemic theory, and the theory of microvascular dysfunction and dynamic left ventricular gradient induced by elevated circulating catecholamine levels. Adequate management of Tako-tsubo syndrome demands immediate preparation for coronary angiography. Once the diagnosis is made, treatment is primarily symptomatic and includes monitoring for complications. Patients with Tako-tsubo syndrome most frequently develop acute LV failure, pulmonary edema, rhythm and conductive disturbances and apical thrombosis. Treatment is symptomatic and includes administration of diuretics, vasodilators and mechanical support of circulation with intra-aortic balloon counterpulsation.

Assessment of respiratory compensation phase during graded exercise in patients with chronic heart failure.

BACKGROUND: The VE-VO2 relationship during graded exercise has an inflection point beyond the ventilatory anaerobic threshold (VAT) termed the respiratory compensation point (RCP). Metabolic variables analyzed at the level of VAT and RCP may contribute to the better understanding of such limiting symptoms in chronic heart failure (CHF) patients as dyspnea and early fatigue. The AIM of the present study was to analyze the RCP during symptom limited ramp exercise testing in CHF patients. PATIENTS AND METHODS: Forty six CHF patients (II and III NYHA functional class; age = 51 +/- 9 years, LVEF% = 35% +/- 6%; mean +/- SD) and 20 matched controls performed graded cardiopulmonary exercise test on a cycle ergometer. RESULTS: The duration and productivity of RCP (delta(x) = peak(x) - VAT(x)) in patients were significantly (p < 0.001) reduced compared to healthy subjects: delta duration = 3.0 +/- 1.2 vs 4.3 +/- 1.5 min, delta watts = 24.3 +/- 11.5 vs. 39.4 +/- 11.5, delta VO2/kg (ml.kg-1 x min-1) = 3.8 +/- 1.3 vs 8.8 +/- 2.3. An important characteristic of this phase was the higher subjective cost of physical effort assessed by Borg scale and Watts/Borg ratio (Borg peak = 9.9 +/- 0.4 vs. 6.0 +/- 1.2; p < 0.001, Watts/Borg peak = 9.2 +/- 2.3 vs 23.9 +/- 6.4, p < 0.001). The relative hyperventilation of patients on the basis of the watt exercise can be seen in the values of derivative index V (ml x min-1 x watt-1) 478 +/- 59 vs 568 +/- 118; (p < 0.001) in controls and patients, respectively. CONCLUSIONS: The impaired efficiency of oxygen delivery systems in patients with CHF is what causes the appearance of early limiting symptoms. Duration and productivity of respiratory compensation phase in CHF patients are considerably reduced compared to controls.

Chronic kidney disease, cardiovascular risk, and response to angiotensin-converting enzyme inhibition after myocardial infarction: the Survival And Ventricular Enlargement (SAVE) study.

BACKGROUND: Persons with end-stage renal disease and those with lesser degrees of chronic kidney disease (CKD) have an increased risk of death after myocardial infarction (MI) that is not fully explained by associated comorbidities. Future cardiovascular event rates and the relative response to therapy in persons with mild to moderate CKD are not well characterized. METHODS AND RESULTS: We calculated the estimated glomerular filtration rate (eGFR) using the 4-variable Modification of Diet in Renal Disease method in 2183 Survival And Ventricular Enlargement (SAVE) trial subjects. SAVE randomized post-MI subjects (3 to 16 days after MI) with left ventricular ejection fraction < or =40% and serum creatinine <2.5 mg/dL to captopril or placebo. Cox proportional hazards models were used to evaluate the relative hazard rates for death and cardiovascular events associated with reduced eGFR. Subjects with reduced eGFR were older and had more extensive comorbidities. The multivariable adjusted risk ratio for total mortality associated with reduced eGFR from 60 to 74, 45 to 59, and <45 mL x min(-1) x 1.73 m(-2) (compared with eGFR > or =75 mL x min(-1) x 1.73 m(-2)) was 1.11 (0.86 to 1.42), 1.24 (0.96 to 1.60) and 1.81 (1.32 to 2.48), respectively (P for trend =0.001). Similar adjusted trends were present for CV mortality (P=0.001), recurrent MI (P=0.017), and the combined CV mortality and morbidity outcome (P=0.002). The absolute benefit of captopril tended to be greater in subjects with CKD: 12.4 versus 5.5 CV events prevented per 100 subjects with (n=719) and without (n=1464) CKD, respectively. CONCLUSIONS: CKD was associated with a heightened risk for all major CV events after MI, particularly among subjects with an estimated glomerular filtration rate <45 mL x min(-1) x 1.73 m(-2). Randomization to captopril resulted in a reduction of CV events irrespective of baseline kidney function.